Letter to MCI by the President, Indian Society of Toxicology

Letter has been sent to the Chairperson and all members of the MCI BOG on behalf of the Indian Society of Toxicology..............

Dear Colleagues,

Please find attached a copy of the letter that has been sent to the Chairperson and all members of the MCI BOG on behalf of the Indian Society of Toxicology. The letter is drafted in such a way that while the emphasis is on uplifting toxicology in the UG curriculum, forensic medicine is being highlighted as the department that must be given this responsibility. In other words, there is no question of fragmenting forensic medicine as is being envisaged by the MCI BOG, but that it must be strengthened into a full-fledged speciality and included in the clinical phase of MBBS course with two separate papers.

When one goes through the document prepared by the MCI BOG (Vision-2015), one will notice the total lack of mention with regard to forensic pathology. In fact, it appears that new private medical colleges need not even have a mortuary or conduct forensic autopsies. It is evident that the new curriculum indicates that exposure of MBBS students to forensic autopsies is not essential, but only "elective". Very reluctantly, the document supports the retention of forensic medicine as a fragmented entity, with focus mainly on medical ethics, clinical forensic medicine and toxicology. Perhaps there is some merit in removing unnecessary details pertaining to forensic pathology, which many doctors do not require when they take up specializations in other fields. For those who end up in peripheral govt hospitals where autopsies are mandatory, the MCI is likely to suggest a refresher course to be imparted by forensic medicine dept of a medical college nearby.

Therefore, our fight to retain forensic medicine in UG curriculum must be such that the MCI BOG is convinced about its actual utility for the majority of doctors graduating with an MBBS degree. Thus, while forensic pathology can be the cornerstone as always, we must include those areas considered essential for basic MBBS doctors, but which were never given the importance that they deserved all these years: namely medical ethics, clinical forensic medicine, and toxicology.  Emphasising these areas as significant components of forensic medicine will have the added benefit of anticipated support from clinical colleagues to retain the latter, and in fact can facilitate its entry into the clinical phase of MBBS. The blinkered, time honoured approach of only harping on autopsy-related teaching may not work to our advantage any more.  

I feel that a similar kind of letter must be sent by IAFM, KAMLS, SIMLA, etc., with appropriate changes stressing the importance offorensic medicine as a complete speciality encompassing clinical forensic medicine, medical ethics, forensic pathology and toxicology. Only then can we continue to survive as teaching specialists, and not get relegated to a non-teaching postgraduate speciality with just a few lectures for UGs scattered here and there.

With regards,

V.V.Pillay MD, DCLChief, Poison Control Centre
Head, Dept of Analytical Toxicology & Forensic Biotechnology
Professor, Forensic Medicine & Medical Toxicology
Amrita Institute of Medical Sciences & Research
Cochin, Kerala  682041
India

To,
Dr SK Sarin
Chairperson, Board of Governors
Medical Council of India
Pocket - 14, Sector - 8
Dwarka Phase - 1
New Delhi – 110077

Dear Sir,
At the outset, let me wish you and all the other distinguished members of the Board of Governors of the MCI, on behalf of the Indian Society of Toxicology, a very happy new year.
I am writing this letter in the capacity of the President, Indian Society of Toxicology, headquartered currently in Amrita Institute of Medical Sciences & Research, Cochin, Kerala.
This is with reference to the proposed new curriculum for undergraduate medical education as outlined in the document “Vision 2015” (posted in the MCI website at the following URL: http://www.mciindia.org/MediaRoom/Announcements.aspx).
We have some concerns about some of the points mentioned, which we feel can adversely impact the teaching of toxicology (besides forensic medicine) to undergraduate medical students. I am sure that you are well aware of the terrible scenario with regard to poisoning and drug overdose in our country, the incidence of which is among the highest in the world. For long, the subject of toxicology has been neglected at the UG level, as a result of which a basic doctor with an MBBS degree has very little idea about practical aspects (clinical and forensic) of management of such cases. The problem is compounded further at the PG level, since toxicology is not a significant component of either general medicine, pharmacology or forensic medicine. So, even at specialist level, a physician has very little inkling about effective handling and management of poisoning cases, leading to high mortality (the highest in the world), as well as miscarriage of justice in fatal cases with criminal overtones.
The Indian Society of Toxicology was started 7 years ago to specifically address these problems plaguing medical toxicology in India, and to improve the status of this neglected speciality. Since then, some progress has been made, and we have succeeded to a great extent in highlighting the importance of this speciality by holding conferences and workshops all over the country, publishing a peer-reviewed journal regularly (Journal of Indian Society of Toxicology or JIST), besides two resource books on poisoning for physicians (one a handbook, and the other a reference book), and starting a full-fledged Poison Control Centre (PCC) with information resource and analytical facilities at Cochin (which is recognized by the WHO).
The PCC provides information and guidance to physicians and the lay public from any part of Kerala State on matters pertaining to poisons, poisoning, drug overdose, bites and stings, etc., free of charge on a round-the-clock basis, besides analyzing body fluid samples from victims of poisoning for qualitative and quantitative estimation of poisons or drugs. The PCC also runs training programs on toxicology for students and faculty of medicine on emergency toxicology, bedside toxicology, analytical toxicology, etc.
We feel that the MCI must insist that similar centres be started by forensic medicine departments of all medical colleges, in addition to running clinical forensic and autopsy services, so that there would be proper assistance to physicians managing poisoning cases and the morbidity/mortality can be brought down to acceptable levels.
Unfortunately, we feel that the document “Vision 2015” is retrogressive with regard to toxicology and may undermine all the efforts that we have been making in ameliorating the dismal scenario of poisoning in India. This will further dilute the importance of this speciality among students and faculty of medicine leading to even more neglect.

The following are our humble submissions and suggestions for your urgent attention in rectifying the anomalies in “Vision 2015”:

1. Till such time that a separate speciality of medical toxicology is created, the subject of toxicology must remain with forensic medicine as it exists now, and not be broken and attached in a piece-meal fashion to various departments (pharmacology, clinical medicine, etc). This will lead to overlap, confusion and disarray. 
2. The toxicology component of forensic medicine must be at least one half or one third of the total subject at UG and PG levels. 
3. The subjects of forensic medicine & toxicology must be taught along with clinical subjects in the clinical phase of MBBS course. There should be a full-fledged university examination for these subjects with two separate papers (vide infra). It is inappropriate to include these subjects in the para-clinical phase along with pathology, microbiology, etc., because unlike the latter, neither forensic medicine nor toxicology falls in the category of basic medical sciences. 
4. Teaching of toxicology must be comprehensive with emphasis on clinical, analytical, and forensic aspects. For this purpose, there must be an integrated approach with relevant departments (clinical medicine, emergency medicine, biochemistry, pharmacology, etc). The coordinating department should be forensic medicine, since almost all poisoning cases are medicolegal in nature with substantial forensic implications. 
5. The practical aspect of toxicology must include case-taking in poisoning/overdose, along with basic analytical exercises, and forensic autopsy exposure. 
6. There should be a separate paper for toxicology in the university examination, i.e., the broad speciality of forensic medicine must have 2 papers (with equal weightage of marks): Paper 1 – Medical Jurisprudence (including Medical Ethics) & Forensic Pathology; Paper 2 – Clinical Forensic Medicine & Toxicology 

These are a few suggestions that if implemented effectively, will go a long way in improving the teaching of forensic medicine and medical toxicology at the UG level, which will enable even a basic doctor working in a peripheral hospital or managing a nursing home to undertake the clinical and forensic management of assault and poisoning cases with confidence, as well as identify and investigate cases involving foul play more effectively.

With regards,
Yours sincerely,

Dr V V Pillay, MD, DCL 

Copies:

1. Dr SK Sarin 
2. Prof Ranjit Roy Chaudhury
3. Dr. Sita Naik
4. Prof RN Salhan
5. Dr Devi Prasad Shetty 
6. Prof Gautam Sen